Which androgens (male hormones) should be evaluated in a female with hirsutism (abnormal hair growth)?

From the Guidelines

For abnormal hair growth in a girl, the key male hormones that should be checked include total testosterone (TT) and calculated free testosterone (cFT), as they have the highest diagnostic accuracy for biochemical hyperandrogenism in polycystic ovary syndrome (PCOS) with a pooled sensitivity of 0.74 and 0.89, respectively, and specificity of 0.86 and 0.83, respectively, as reported in the 2025 study by 1. These tests should be part of a comprehensive evaluation to identify potential causes such as PCOS, congenital adrenal hyperplasia, or other androgen-secreting conditions. Some key points to consider when checking for abnormal hair growth in girls include:

• Testing should ideally be performed in the early morning and during the follicular phase of the menstrual cycle for accurate results.
• Additional relevant tests include luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and thyroid function tests to provide a complete hormonal profile.
• Excess androgens in females can stimulate hair follicles to produce thicker, darker hair in a male-pattern distribution, and early identification of hormonal imbalances allows for appropriate treatment to address both the underlying cause and the distressing symptom of abnormal hair growth, as noted in the study by 1.
• The 2023 International PCOS Guidelines, informed by the study by 1, recommend using TT and FT as the first-line laboratory tests to assess biochemical hyperandrogenism in the diagnosis of PCOS, with cFT assessed by equilibrium dialysis or ammonium sulfate precipitation, or calculated using FAI.
• If TT or cFT are not elevated, androstenedione (A4) and dehydroepiandrosterone sulfate (DHEAS) could also be considered, noting their poorer specificity, as reported in the study by 1.

From the Research

Male Hormones and Abnormal Hair Growth in Girls

To determine which male hormones should be checked for abnormal hair growth in girls, it's essential to understand the underlying causes of hirsutism.

• Hirsutism is defined as excess hair growth in androgen-dependent areas of the body in women 2.
• The majority of patients with hirsutism have a benign process that may be idiopathic, but in some cases, it can be a sign of functional ovarian hyperandrogenism or congenital adrenal hyperplasia 2.
• Male hormones such as testosterone and dihydrotestosterone (DHT) play a crucial role in the development of hirsutism 3, 4.
• The Ferriman-Gallwey score is a clinical measure used to evaluate the severity of hirsutism, and it assesses the presence and severity of excess hair growth in different areas of the body 3, 5, 4.

Hormones to be Checked

The following male hormones should be checked for abnormal hair growth in girls:

• Testosterone: Elevated levels of testosterone can contribute to the development of hirsutism 3, 4.
• Dihydrotestosterone (DHT): DHT is a potent form of testosterone that plays a key role in the development of hirsutism 3, 4.
• Androstenedione: This hormone can also contribute to the development of hirsutism, especially in cases of polycystic ovary syndrome (PCOS) 3, 4.
• Dehydroepiandrosterone sulfate (DHEA-S): Elevated levels of DHEA-S can be associated with hirsutism, particularly in cases of congenital adrenal hyperplasia 2, 4.

Treatment Options

Treatment options for hirsutism include medications that block the effects of androgens, such as:

• Finasteride: A 5alpha-reductase inhibitor that reduces the conversion of testosterone to DHT 3, 4.
• Flutamide: An anti-androgen that blocks the effects of testosterone and DHT 3.
• Spironolactone: A medication that blocks the effects of androgens and is often used to treat hirsutism in women with PCOS 5, 6.